--- name: gross-to-net-optimization-analyzer description: "Models net realized price for a pharmaceutical product by decomposing gross-to-net across every deduction bucket — rebates, chargebacks, co-pay programs, Medicaid best price exposure, fees, and returns — then quantifies each lever, flags best-price and 340B interactions, and delivers ranked optimization opportunities with a Medicaid best-price impact check. Use when analyzing GTN dynamics, diagnosing net price erosion, evaluating contract or co-pay changes, or building a GTN optimization plan for a branded pharma product." argument-hint: "[product] [channel-mix]" allowed-tools: ["Read"] --- # Gross-to-Net Optimization Analyzer ## Purpose Decompose a pharmaceutical product's gross-to-net waterfall channel-by-channel, quantify each deduction lever, and surface ranked optimization opportunities — while screening every recommendation against Medicaid best price and 340B ceiling-price exposure so net-improving moves don't trigger downstream statutory penalties. ## When to Use Invoke this skill when the user asks to: - Build or analyze a gross-to-net waterfall for a branded product - Diagnose why net realized price is eroding vs. list price growth - Model the net impact of a proposed rebate, co-pay, or contract change - Identify which GTN levers are destroying the most net value - Assess Medicaid best-price or 340B exposure from a contracting decision - Prioritize GTN optimization opportunities ahead of a pricing or budget cycle ## Inputs Required Before starting, collect: - **Product & indication**: Brand name, therapeutic area, and lifecycle stage (launch / growth / mature / LOE-approaching) - **WAC (list price)**: Current wholesale acquisition cost per unit and any recent list price changes - **Channel/payer mix**: % of volume across Commercial, Medicare Part D, Medicaid (FFS + managed), 340B, VA/DoD/FSS, and cash/other - **Contract structures**: Current rebate rates by payer segment, admin fees, chargeback terms, and any value-based or portfolio contracts - **Patient support programs**: Co-pay card design (cap, max benefit, accumulator/maximizer exposure), free drug/PAP volume - **Current GTN**: Reported GTN % or net-to-gross ratio, and the largest deduction buckets if known - **Objective**: Improve net price, defend access, expand volume, or protect best price — with any hard constraints If channel mix percentages are missing, use category-typical splits for the therapeutic area and flag the assumption. If Medicaid best price status is unknown, model both scenarios. ## Instructions ### Step 1: Build the Gross-to-Net Waterfall Construct the full deduction stack from WAC down to net realized price. Express each line as both $/unit and % of WAC: 1. **Gross sales (WAC × volume)** — starting point 2. **Prompt-pay / cash discounts** — typically 2% 3. **Chargebacks** — the gap between WAC and contracted price for 340B, FSS/Big 4, GPO, and other contract-eligible channels 4. **Commercial rebates** — formulary rebates, access rebates, market-share/tier rebates 5. **Medicare Part D rebates** — plan rebates plus the manufacturer coverage gap discount (mandatory 70% in the gap) 6. **Medicaid rebates** — statutory URA (23.1% branded + CPI-U penalty) plus supplemental rebates 7. **Co-pay assistance** — card redemptions net of accumulator/maximizer leakage 8. **Fees** — distribution service fees, admin fees, GPO fees, data fees 9. **Returns & other** — returns reserve, patient assistance write-offs Sum deductions and report **Net Realized Price** and **GTN %** (net ÷ gross). ### Step 2: Size and Rank the Levers For each deduction bucket, quantify total $ impact and % of total GTN erosion. Rank largest to smallest and label each as: - **Statutory/fixed** (Medicaid URA, coverage gap discount) — limited discretion - **Contractual** (commercial/Part D rebates, chargebacks, fees) — negotiable - **Discretionary** (co-pay design, supplemental rebates, VBCs) — full control Concentrate optimization attention on contractual and discretionary levers; statutory levers are managed, not optimized. ### Step 3: Medicaid Best Price & 340B Screen Before recommending any lever change, run the guardrail check: - **Best price test**: Identify the lowest net price offered to any eligible commercial customer — this sets Medicaid best price and, via the ceiling price formula, drags the 340B price down - **Trigger risks**: Deep single-customer commercial discounts, aggressive supplemental rebates, and certain co-pay/VBC structures can reset best price - **Exemptions to leverage**: Bona fide service fees at fair market value, nominal price sales to eligible entities, and properly structured co-pay assistance may be excluded from best price when designed correctly - Flag any proposed move that would lower best price and estimate the Medicaid + 340B spillover cost ### Step 4: Channel-Level Net Economics Compute net realized price for each channel separately (Commercial vs. Part D vs. Medicaid vs. 340B vs. cash). Identify: - Which channels are net-accretive vs. net-dilutive - Whether volume is shifting toward lower-net channels (mix erosion) - 340B penetration trend and its compounding effect on chargebacks ### Step 5: Optimization Opportunities (Ranked) Generate 8–10 opportunities ranked by expected net-price impact, each with: the lever, the mechanism, estimated net $ impact directionally, best-price/340B risk rating, and access trade-off. Draw from: - **Rebate architecture**: Shift flat rebates to market-share tiers; right-size access rebates against realized formulary position - **Co-pay program redesign**: Deploy accumulator/maximizer countermeasures, cap max benefit, tighten eligibility to reduce leakage - **Contract rationalization**: Trim contracts delivering rebate without access; renegotiate fees above FMV - **Channel mix management**: Manage 340B eligibility verification and duplicate-discount prevention; steer to net-accretive channels where compliant - **Value-based contracting**: Structure outcomes-based deals that protect best price via proper accounting treatment - **Gross price strategy**: Assess WAC actions against CPI-penalty and coverage-gap exposure ### Step 6: Quantified Scenario & Net Impact Summary Model a base case vs. optimized case GTN waterfall side by side. Show the net-price delta, the GTN % improvement, and the estimated annual net revenue impact. Include the best-price impact check for the optimized scenario. ## Output Format - **Structure**: GTN waterfall table → lever ranking → best-price/340B screen → channel-level economics → ranked opportunities → base vs. optimized scenario - **Length**: 1,000–1,400 words - **Format**: Tables for the waterfall and channel economics; ranked numbered list for opportunities; prose for the best-price screen and summary - **Sections**: Gross-to-Net Waterfall → Lever Sizing & Ranking → Medicaid Best Price & 340B Screen → Channel-Level Net Economics → Ranked Optimization Opportunities → Base vs. Optimized Scenario - **Tone**: Pricing/access director — quantitative, compliance-aware, decision-oriented; flags trade-offs explicitly rather than overpromising net gains ## Quality Checklist Before delivering output, verify: - [ ] The waterfall includes all nine deduction buckets and reconciles from gross to a stated Net Realized Price and GTN % - [ ] Each line item is expressed in both $/unit and % of WAC - [ ] Levers are labeled statutory / contractual / discretionary and ranked by $ impact - [ ] Every recommended optimization carries a best-price/340B risk rating — no lever change is proposed without the screen - [ ] Channel-level net price is computed separately for at least Commercial, Part D, Medicaid, and 340B - [ ] The base vs. optimized scenario shows a quantified net-price delta and annual net revenue impact ## Notes - The largest single controllable lever in most branded portfolios is commercial rebate architecture, not co-pay — but co-pay leakage from accumulators/maximizers is frequently the most underestimated erosion source - Never recommend a net-improving commercial discount without checking whether it becomes the new Medicaid best price — a small commercial gain can create a much larger statutory loss - Bona fide service fees and correctly structured VBCs are the two most reliable ways to deliver value without resetting best price - When channel mix data is directional rather than exact, present the waterfall as a range and identify the assumption driving the widest sensitivity --- ## How to use this skill This file is a Claude Code skill in [Anthropic's standard format](https://docs.anthropic.com/en/docs/claude-code/skills) — markdown with YAML frontmatter at the top. **Installing in Claude Code:** - `~/.claude/skills//SKILL.md` — auto-loads in every session anywhere on your machine (recommended for skills you'll use across multiple projects) - `/.claude/skills//SKILL.md` — auto-loads only when working in that project (recommended for project-specific skills) Restart Claude Code or open a new session to register. **Using in Claude.ai, ChatGPT, Gemini, or other AI tools:** 1. 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